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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
In the name of God
Shiraz E-Medical Journal
Vol. 8, No. 4, October 2007
http://semj.sums.ac.ir/vol8/oct2007/echo.htm
An Alternative Method for Perioperative Estimation of Pulmonary
Artery Systolic Pressure by Echocardiography.
Karvandi M*, Piranfar MA*, Ghaffaripour M**, Behnia M*, Gheidari M*, Mohammadi Tofigh A .
* Assistant Professor, Section of Echocardiography, Department of Cardiology, Taleghani Hospital,
Shahid Beheshti University of Medical Sciences, Tehran, Iran, ** Assistant Professor, Section of Cardiac Anesthesia, Department of Anesthesiology and Intensive Care, Lavasani Heart Center, Tehran,
Iran, ( Assistant Professor, Department of Surgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Correspondence: Dr. Arash Mohammadi Tofigh, Section of Echocardiograpgy, Taleghani Hospital, Evin, Tehran, Iran.
Telephone: +98(21)22432576, fax: +98(21)77557069, E-mail: [email protected].
Received for Publication: May 21, 2007, Accepted for Publication: September 12, 2007.
Abstract:
Backgrounds: In the perioperative setting, pulmonary hypertension is due to ischemia, left-sided valvular regurgitation and stenosis, residual shunt, pulmonary emboli, pericardial effusion etc. The pulmonary artery (PA) pressure
can be assessed by different methods, including invasive pulmonary catheters and pulsed Doppler echocardiography.
Because of limitations of Doppler echocardiography (conventional method) for evaluation of PA pressure, we
purposed this study to determine whether tricuspid annular plane systolic excursion (TAPSE), isovolumic relaxation
time (IVRT) and S-wave velocity obtained by tissue Doppler imaging (TDI) can be used as indices of systolic
pulmonary artery pressure in perioperative setting.
Materials and Methods: Simultaneously, TAPSE by 2-D echocardiography and tissue Doppler velocity (TDV) study
by Doppler echocardiography and right heart catheterization by Swan-Ganz catheter were performed in 55 patients
(mean age 46 years,30 were male) with left–sided valvular disease (n=25), ischemic heart disease (n=18) and
adult-congenital heart disease (n=12).The TAPSE index ,which is expressed as an absolute value (cm or mm), IVRT
and S-wave velocity by TDI were measured. We also measured pulmonary artery systolic pressure by right cardiac
catheterization.
Results: In patients with moderate and severe pulmonary hypertension (PASP>45mmHg) the TAPSE value was <
17.8 mm with sensivity of 90% and specifity of 80%, the S-wave velocity was <11cm/s with sensivity of 90% and
specifity of 86% and the IVRT was >79ms with sensitivity of 93% and specificity of 95% (p<0.001). Some factors
such as underlying diseases (ischemic heart disease, congenital heart disease) had no effect on this correlation.
Conclusion: We conclude that evaluation of TAPSE index and IVRT and S-wave velocity by echocardiography
provides a simple and rapid method for estimating systolic pulmonary artery pressure in perioperative setting.
Key Words: Pulmonary Artery Systolic Pressure, Echocardiography.
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
Introduction:
Pulsed Doppler tissue imaging tech-
Pulmonary artery pressure is an important hemodynamic variable used in the
management of patients with cardiovascular and pulmonary disease
(1)
. Pulmo-
nary artery pressure is estimated invasively by the tricuspid regurgitation jet
velocity, pulmonary acceleration time,
right ventricular (RV) ejection time, pulmonary regurgitation and isovolumic relaxation time in Doppler echocardiography
(2,3)
. However, finding a reliable non
invasive evaluation of pulmonary artery
pressure is still a problem
(1)
. The aim of
the present study is to investigate the
relationship between Isovolumic Relaxation Time (IVRT) obtained by Doppler
Tissue imaging from tricuspid annulus
motion and pulmonary artery pressure in
patients with valvular, coronary and congenital heart disease.
nique: A commercially reliable ultrasound
system
(GE
VIVID
SEVEN)
equipped with a multi frequency phased
array transducer of M3S, and pulsed
Doppler tissue imaging technique was
used for transthoracic echocardiography
(TTE) in 35
patients and
a ACUSON
SECUOIA 512 for transesophageal echocardiography (TEE) in the other 20 patients. We used TEE for intraoperative
cases and cases with very poor view imaging in TTE ,like patients who were under mechanical ventilation or patients
with nonvisible lateral RV wall in TTE
(4,5)
.
All patients were in stable hemodynamic
condition and tracing were recorded during end expiration. The tricuspid annular
systolic and diastolic velocities and the
time intervals were acquired in apical
four-chamber views at the junction of the
right ventricle free wall and the anterior
leaflet of the tricuspid valve by tissue
Doppler imaging.6 The acoustic power
Materials and Methods:
Study
population:
Tricuspid
and filter and gain were adjusted for deannular
plane systolic excursion (TAPSE) by 2-D
echocardiography
and
Tissue
Doppler
velocity (TDV) study by Doppler echocardiography and right heart catheterization
by balloon-tipped flow directed pulmonary artery catheter (Swan-Ganz catheter) were performed in 35 patients in the
open heart intensive care unit and 20
patients in open heart operation room
which were randomly elected. Our exclusion data were right ventricular myocardial infarctions and previously operated
patients. Patient consent was obtained in
all
cases.
tecting myocardial velocities
(7,8,9)
.
The peak systolic (Sa), peak early diastolic (Ea), peak late diastolic (Aa) annular velocities and the time between the
end of Sa and the beginning of Ea were
obtained by placing a sample volume
with a fixed length of 0.52 cm at the
junction of RV free wall and the anterior
leaflet of the tricuspid valve when imaged
from the two-dimensional four chamber
view by using Doppler tissue imaging
(6,10)
. All recording were made at a sweep
speed of 50 and 100 mm/s. All recording
were made with a simultaneous superimposed ECG
(11,12)
. Values are presented
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
as means of 3 consecutive beats(4). (fig.
nary artery pressure (SPAP) and wedge
1 and 2)
pressure
were
measured.
Left ventricular ejection fraction (LVEF)
was not included in this study. The echo-
Statistical
cardiographic measurements were per-
available statistical program (SPSS 10.1
formed before the Swan-Ganz catheter
and 11.1) was used. Clinical, echocardio-
measurements in all cases so the echo-
graphic, and right heart catheterization
cardiographic studies performers were
data expressed as mean ± standard de-
not aware from the systolic pulmonary
viation. Pearson’s correlation and linear
artery
regression analysis were plotted to show
pressures
of
patients.
analysis:
A
commercially
certain relationship. A p-value less than
TAPSE (Tricuspid annular plane sys-
0.05
tolic excursion)
study protocol was approved by the Insti-
During
ventricular
systole,
long
was
considered
significant.
The
axis
tutional Review Board of Shahid Beheshti
shortening is created by motion of both
University of Medical Sciences, Tehran,
atrioventricular valve annulae toward the
Iran.
cardiac apex. Because the septal attachment of the tricuspid annulus is relatively
fixed; the majority of tricuspid annular
motion occurs in its lateral aspect. This
gives the motion of the tricuspid annulus
a hinge-like appearance, moving more
laterally than medially. This motion contracts with that of the mitral annulus;
which has a more symmetrical or piston–
like appearance during systole. Tricuspid
annular plane systolic excursion (TAPSE)
describes this long axis systolic excursion
of the lateral aspect of the tricuspid annulus; and it has validated as a useful
additional measure of global RV systolic
function (fig. 3).Measurement of TAPSE
can
be
expressed
as
an
absolute
value(cm or mm) or as a maximal majoraxis
Cardiac
shortening
fraction
catheterization:
A
(13)
.
balloon-
tipped flow directed pulmonary artery
catheter (Swan – Ganz catheter) was
used for hemodynamic measurements.
The catheter was inserted in the internal
jugular vein in all cases. Systolic pulmo-
Results:
General characteristics of the study
population: The study population comprised 25 female and 30 male subjects,
ranging in age from 18 to 73 years
(mean 46±3.3 years). 25 patients had
aortic and mitral valve disease. 12 patients had congenital heart disease and
18 patients had coronary artery disease.
The referral diagnoses are presented in
table 1. The patients were divided into
two groups by the values obtained from
Swan-Ganz catheter; group I: pulmonary
artery systolic pressure in 25-45mmHg
range (n=31), group II: in 46-80 mmHg
range (n=24) (table 2).
Relationship between Right ventricular isovolumic relaxation time, Swave velocity, TAPSE and pulmonary
artery pressure: A significant relationship was found between the IVRT, Swave velocity, TAPSE and pulmonary artery systolic pressure (r= 0.99,
P<0.0001). (Fig 4, 5, 6)
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
Fig. 1, Schematic traces from Doppler tissue imaging with superimposed ventricular and atrial pressures. IVC: Isovolumic contraction velocity, Sv: Systolic velocity during ejection period, Ev: Early diastolic velocity, Av: Atrial velocity, IRT: Isovolumic relaxation time.
Fig. 2, Illustration of pulsed TDI of TV in a patient with MR. Sa: Peak systolic velocity at the anterior
leaflet of TV, Ea: Peak early diastolic velocity at the anterior leaflet of TV, IVRT: The time between the
end of Sa and the beginning of Ea.
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
Fig. 3, Measurement of tricuspid plane sytolic excursion (TAPSE) measured during diastole (Top) and systole (Bottom)
The IVRT, S-wave, TAPSE values showed
The IVRT value has been compared in
significant differences between the two
the two groups; group I: 51.79 ms
groups (P<0.0001). In patients with sig-
±13.35 STD, group II: 91msec ± 11.7
nificant
STD (table 3).The S-wave value has been
(PASP>45mmHg) the TAPSE value was
compared in the two groups; group I:
<17,8mm with sensivity of 90% and a
13±2cm/s STD, group II: 10± 2 STD
specifity
(table 3).
<11cm/s with sensivity of 90% and a
The TAPSE value has been compared in
specifity of 86% and IVRT>79msec with
the two groups; group I: 23±3mmSTD,
sensivity of 93% and a specifity of 95 %
group II: 18±1 STD (table 3).
(p<0.0001).
pulmonary
of
80%,
hypertension
S-wave
velocity
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
Table 1- Referral diagnosis of patients
Diagnosis
VHD
(n)
CAD
(n)
CHD
(n)
N
MS
MS+MR
AS+AI
AS
AI
AI+MS
MR+AI
7
4
4
2
2
3
3
CAD+ISCHEMIC MR
PURE CAD
8
10
ASD
VSD
7
4
25
18
SMALL PDA
1
12
VHD: valvular heart disease, MS: mitral stenosis, MR: mitral regurgitation, AS: aortic stenosis, AI:
aortic insufficiency, CAD: coronary artery disease, CHD: congenital heart disease, ASD: atrial septal
defect, VSD: ventricular septal defect.
Table 2- Systolic pulmonary artery pressure in two groups of patients based on Swan-Ganz catheter
measurement.
Group
I
II
SPAP (mm hg)
N
25-45
46-68
31
24
SPAP: systolic pulmonary artery pressure
Table 3- Echocardiographic measurements in two groups
index
Group I
Group II
S-wave Velocity (cm/s)
13±2
10±2
IVRT (msec)
51.79±13.35
91±11.7
TAPSE (mm)
23±3
17±1
TAPSE = TV annular plane systolic excursion; S-wave = systolic wave in TDI; IVRT= Isovolumic relaxation time.
Fig. 4, Correlation between IVRT (Isovolumic Relaxa-
Fig. 5, Correlation between S-wave velocity and PASP
tion Time) and PASP (pulmonary systolic artery pres-
(pulmonary systolic artery pressure)
sure)
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
itself to measurement variability and error
(3)
. Determination of TR-jet and Tim-
ing need good views and resolution in 2D
and conventional Doppler echocardiography. Thus, in patients with poor view imaging or patients without TR-jet, pulmonary pressure measurement is not possible by TR peak velocity and gradient
measurement. But, for evaluation of tricuspid annular motion (TAPSE) by 2-D
Fig. 6, Correlation between TAPSE (tricuspid annular
echocardiography or Tissue-Doppler ve-
plane systolic excursion) and PASP (pulmonary sys-
locity study, a visible lateral (free) wall of
tolic artery pressure)
right ventricle is adequate which is independent of the quality and resolution of
images in 2D-echocardiography.
Diastolic RV dysfunction (lower tricuspid
Discussion:
valve peak E velocity in TV inflow, lower
We have demonstrated that isovolumic
E/A velocity and prolonged RV IVRT) and
relaxation time of the right ventricular
Systolic RV dysfunction (lower tricuspid
free wall measured by pulsed Doppler
valve peak S-wave and lower TAPSE) has
tissue imaging, systolic velocity of tricus-
been demonstrated in patients with pul-
pid
monary hypertension and in those with
valve
(TV)
annulus
obtained
by
pulsed Doppler tissue imaging and tri-
symptomatic
cuspid annular plane systolic excursion
even in the absence of pulmonary hyper-
by 2D echocardiography can be used to
tension, suggesting a potential role for
estimate pulmonary artery pressure in
ventricular interdependence in impaired
the perioperative setting. Previous inves-
RV filling
tigators have described the use of vari-
prolonged significant pulmonary hyper-
ous Doppler parameters to evaluate pul-
tension resulting RV remodeling (dilata-
monary pressure. These efforts have fo-
tion and dysfunction), lead to increased
cused on timing of events such as right
IVRT and decreased S-wave velocity and
ventricular
TAPSE
pre-ejection
time,
ejection
(3)
(18)
congestive
heart
failure,
. It must be mentioned that
.
time, tricuspid regurgitation (TR) jet and
Thus we used TDI for precise determining
IVRT (by conventional Doppler echocar-
of peak systolic velocity, the time interval
diography). The right ventricular iso-
between the end of peak systolic velocity
volumic relaxation time is the interval
(Sa) and the beginning of early diastolic
between pulmonic valve closure and tri-
(Ea) in tricuspid annular velocities and 2-
cuspid valve opening. Based on previous
D echocardiography for absolute value of
studies, this time increases with pulmo-
TV annular excursion (TAPSE), along with
nary hypertension
(3, 14-17)
. In adults,
simultaneous electrocardiography.
pulmonic valve closure is difficult to as-
In a recent study, Per Lindquist et al.
certain, and the short time interval tends
showed that isovolumic contraction ve-
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Shiraz E-Medical Journal, Vol. 8, No. 4, October 2007
locity can be useful in detection of pa-
Doppler tissue imaging and TAPSE by 2D
tients with elevated right ventricular fill-
echocardiography
ing pressure such as patients with pul-
rapid and non invasive tool for estimating
(4)
provides
a
simple,
. Bolca et al.
of pulmonary hypertension in patients
showed that IVRT is a reliable measure-
with Valvular, Coronary and Congenital
ment of pulmonary artery pressure and
heart disease in perioperative setting.
monary hypertension
vascular resistance with valvular and
congenital heart disease by using Doppler tissue imaging
(19)
.
Kaul S et al. showed that compared with
radionuclide RV ejection fraction as the
reference method for assessing global RV
function, TAPSE has been found to correlate more closely percent change in RV
area during systole
(20)
and Meluzin J et al
conclude that systolic velocity of tricuspid
annular systolic motion could estimate
RV function, in the other hand, S-wave
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